Healthcare Provider Details

I. General information

NPI: 1083601264
Provider Name (Legal Business Name): SHIRLEY M PRYOR ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 1ST AVE N PO DRAWER N
ILWACO WA
98624
US

IV. Provider business mailing address

176 1ST AVE N PO DRAWER N
ILWACO WA
98624
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3747
  • Fax: 360-642-3361
Mailing address:
  • Phone: 360-642-3747
  • Fax: 360-642-3361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30003770
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: